Medical Travel Refund Request

• Legal Form Number: OWCP-957
• Issuer: Office of Workers' Compensation Programs
• Section: U.S. Department of Labor

U.S. Department of Labor

Office of Workers' Compensation Programs

Medical Travel Refund Request

OMB No. 1240-0037

NOTE: This report is authorized by the Federal Employees' Compensation Act (5 USC 8103(a)), the Black Lung Benefits Act (30 USC 901;

20 CFR 725.406 and 725.701) and the Energy Employees Occupational Illness Compensation Program Act of 2000, (42 USC 7384 and

20 CFR 30.701). While you are not required to respond, this information is required to obtain reimbursement for travel expenses. The

method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974 and OMB Circ. 130. This form

should be used for medically related travel covered by the Federal Employees' Compensation Act, the Black Lung Benefits Act and the

Energy Employees Occupational Illness Compensation Program Act of 2000.

Expires: 06/30/2024

2. Case/Claim Number:

1. Claimant's Name (Last, First, Mi.):

3. Payee's Name if different from claimant's name (last, first, mi.): (See Instruction No. 3 for further requirements if payee is not the claimant)

4. Claimant's/Payee's Address (Street/RFD, City, State, Zip Code. See Instruction No. 4 for address requirements if claim is filed under the Division of

Federal Employees' Compensation):

1. See reverse side of form for complete instructions and attachment of receipts.

2. Physician's signature or facsimile is REQUIRED by BLACK LUNG for verification of each service date and type.

Special Instructions:

5a. Date of Travel:

b.

✑

✒

Round TripOne-way

c. Travel From:

Hospital

Office/clinic

Lab

Home

★❏▲❐❉▼❁●

✯❆❆❉❃❅✣●❉■❉❃

✬❁❂

★❏❍❅

d. Travel To:

Hospital

Office/clinic

Lab

Home

★❏▲❐❉▼❁●

✯❆❆❉❃❅✣●❉■❉❃

✬❁❂

★❏❍❅

e. Medical Facility Name and Address

f. Total expense/cost

Taxi $

Bus/Train

Tolls/Pkg

Lodging

Meals

Other

(Specify)

g. Private Auto Only

Miles traveled

DOL USE ONLY

TOS/Procedure Code

$

Total $

h. To be completed by Physician:

(Mark one box only)

Care Rendered

Treatment for Black Lung

Not Black Lung Related

Determine, Test for Black Lung

Diagnosis

(Signature of Physician)

(Date Care Rendered)

✑

✒

✓

FOR BLACK LUNG USE ONLY

6a. Date of Travel:

b.

✑

✒

Round TripOne-way

c. Travel From:

Hospital

Office/clinic

Lab

Home

★❏▲❐❉▼❁●

✯❆❆❉❃❅✣●❉■❉❃

✬❁❂

★❏❍❅

d. Travel To:

Hospital

Office/clinic

Lab

Home

★❏▲❐❉▼❁●

✯❆❆❉❃❅✣●❉■❉❃

✬❁❂

★❏❍❅

e. Medical Facility Name and Address

f. Total expense/cost

Taxi $

Bus/Train

Tolls/Pkg

Lodging

Meals

Other

(Specify)

g. Private Auto Only

Miles traveled

DOL USE ONLY

TOS/Procedure Code

$

Total $

h. To be completed by Physician:

(Mark one box only)

Care Rendered

Treatment for Black Lung

Not Black Lung Related

Determine, Test for Black Lung

Diagnosis

(Signature of Physician)

(Date Care Rendered)

✑

✒

✓

FOR BLACK LUNG USE ONLY

7a. Date of Travel:

b.

✑

✒

Round TripOne-way

c. Travel From:

Hospital

Office/clinic

Lab

Home

★❏▲❐❉▼❁●

✯❆❆❉❃❅✣●❉■❉❃

✬❁❂

★❏❍❅

d. Travel To:

Hospital

Office/clinic

Lab

Home

★❏▲❐❉▼❁●

✯❆❆❉❃❅✣●❉■❉❃

✬❁❂

★❏❍❅

e. Medical Facility Name and Address

f. Total expense/cost

Taxi $

Bus/Train

Tolls/Pkg

Lodging

Meals

Other

(Specify)

g. Private Auto Only

Miles traveled

DOL USE ONLY

TOS/Procedure Code

$

Total $

h. To be completed by Physician:

(Mark one box only)

Care Rendered

Treatment for Black Lung

Not Black Lung Related

Determine, Test for Black Lung

Diagnosis

(Signature of Physician)

(Date Care Rendered)

✑

✒

✓

FOR BLACK LUNG USE ONLY

Form OWCP-957

Revised June 2022

8. Payee's Certification: I certify that the information provided is true and accurate to the best of my knowledge and belief. I am aware that any

person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain reimbursement as

provided by the OWCP, or who knowingly accepts reimbursement to which that person is not entitled is subject to civil or administrative remedies as

well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or

federal criminal conviction for OWCP fraud will result in termination of all current and future OWCP benefits.

Claimant's/Payee's Signature: Date:

If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications,

please contact OWCP. See form instructions for REQUESTS FOR ACCOMMODATIONS OR AUXILIARY AIDS AND SERVICES.

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